TITLE - EFFECT OF VIRTUAL REALITY ON BALANCE IN TBI PATIENTS

REVIEW OF LITERTURE

STUDY AUTHOR YEAR INTERVENTION OUTCOME RESULT CONCLUSION

MEASURE
Virtual reality Ustinova 2014 VR game based Berg balance Improved VR therapy
game-based therapy using Xbox scale , postural is effective
therapy for et al. Kinect Motion Functional Gait stability, in
postural and sensor and assessment gait, and arm improving
coordination projected onto an test , Klock- movements, motor
abnormalities 82-inch screen - gether Ataxia sustained at function
in TBI 15 sessions, each scale, follow-up and balance
50–55 minutes in Functional in TBI
duration, scheduled Reach test patients
2–3 times a week
over-5–6
consecutive weeks.

Results From Candace 2019 Participants were : Community : No This study did not
a Randomized Teferteller randomized into two Balance and significant find that VR
Controlled groups: traditional Mobility Scale between- training was more
et al.
Trial to balance HEP or VR (CB&M); group beneficial than a
Address HEP. The focus of Secondary: differences traditional HEP for
Balance each program was Balance were improving balance.
Deficits After based on the Evaluation observed in However,
Traumatic participant's weakest Systems Test the CB&M individuals with
Brain Injury BESTest subscale. (BESTest), over the chronic TBI in
For example, those Activities- study both treatment
with low stability of Specific duration groups
gait practiced single Balance (PZ.9983) for demonstrated
limb stance in both Confidence individuals improvements in
the VR and Scale (ABC), who received balance in
traditional groups. Participation VR compared response to these
Exercise difficulty Assessment to those who interventions
was determined by with received a which were
the CB&M score. Recombined HEP to completed
Both groups Tools- address independently in
completed their Objective balance the home
programs 3-4 times (PART-O). deficits after environment.
per week for 12 chronic TBI
weeks, with sessions nor in any of
lasting 30 minutes. the secondary
outcomes:
A physical therapist BESTest
(PT) visited (PZ.8822);
participants to ABC
assess home safety, (PZ.4343)
set up the VR and PART-O
system, and provide (PZ.8822).
additional However,
instructions. After both groups
week 6, exercise demonstrated
difficulty was significant
adjusted based on improvement
CB&M scores. s in CB&M
Participants logged and BESTest
daily sessions and from baseline
any adverse events. to 6, 12, and
at 12 weeks
follow-up (all
P’s <.001).
Regardless of
treatment
group, 52%
of
 participants
met or
exceeded the
minimal
detectable
change of 8
points on the
CB&M at 24
weeks and
38% met or
exceeded the
minimal
detectable
change of
7.81 points
on the
BESTest.

Effectiveness José- 2011 The clinical trial Berg Balance Patients using The results suggest
of a Wii Antonio Gil took place in a Scale ,Anterior eBaViR had a that eBaViR
balance -Gómez1, specialized Reach significant represents a safe
board-based Roberto neurorehabilitation test(staatic improvement and effective
system Lloréns et service at a large balance )Time in static alternative to
(eBaViR) for al. metropolitan stair test , balance (p = traditional
balance hospital. Patients Stepping test , 0.011 treatment to
rehabilitation: attended 20 one- 1 minute in Berg improve static
a pilot hour rehabilitation walking test, 10 Balance balance in the ABI
randomized sessions, with a Minute walking Scale and p = population. These
clinical trial minimum of 3 and test and up and 0.011 in results have
in patients maximum of 5 go test, 30- Anterior encouraged us to
with acquired sessions per week. second Sit-to Reaches reinforce the
brain injury In control sessions, Stand Test) virtual treatment
traditional balance Test (Dynamic compared to with new
exercises were Blance )and a patients who exercises, so an
performed either feedback underwent evolution of the
individually or in questionnaire traditional system is currently
groups, while the therapy. being developed.
trial group followed Regarding
a specific protocol. dynamic
balance, the
Patients were results
assessed by a showed
blinded specialist significant
before and after the improvement
program using over time in
clinical balance all these
scales for both static measures,
and dynamic but no
conditions. Static significant
balance was group effect
assessed with the or group-by-
Berg Balance Scale time
(BBS), Brunel interaction
Balance Assessment was detected
(BBA), and Anterior for any of
Reach Test (ART), them, which
while dynamic suggests that
balance was both
evaluated with tests groups
like the Timed Stair improved in
Test (TST), the same
Stepping Test (ST), way. There
1-Minute Walking were no
Test (1MWT), 10- serious
Meter Walking Test adverse
(10MT), Time “Up events during
treatment in
 and Go” Test either group.
(TUG), and 30-
Second Sit-to-Stand
Test (30SST). A
feedback
questionnaire (SFQ)
was also given to
patients, and
therapists were
informally
interviewed.

The effects of Sofia 2013 the Community Video game : Both groups Video game
video game Straudi1* , Balance & Mobility therapy was improved in therapy is an
therapy on Giacomo Scale (CB&M); ii) delivered using CB&M option for the
balance and Severini2 , the an Xbox 360 scores, but management of
attention in Amira Unified Balance Kinect, with only the VGT chronic traumatic
chronic Sabbagh Scale (UBS); iii) the games from group brain injury
ambulatory Charabati Timed Up and Go "Kinect increased on patients to
traumatic et. Al. test (TUG); iv) Adventures" the UBS and ameliorate balance
brain injury: static balance and v) and "Kinect TUG with and attention
an selective visual Sports" that a between- deficits.
exploratory attention focused on group
study evaluation balance and significance
(Go/Nogo task). mobility tasks (p < 0.05).
like side Selective
stepping, attention
weight shifting, improved
jumping, and significantly
arm reaching. in the VGT
In the first group (p <
session, games 0.01).
were selected
based on the
patients’
abilities and
preferences. In
subsequent
sessions, a
block practice
approach was
used, with
progression
based on the
patients’
success.
Feedback
included visual
and
performance-
based
information.
Each game
session lasted
2–5 minutes,
with rest
periods if
needed. A
physiotherapist
supervised the
sessions to
ensure safety
and provide
feedback.
Virtual Jeffrey P. 2014 Static standing patient Participants This study
reality-based Cuthbert, balance was rehabilitation in the provides a modest
therapy for Kristi assessed using the facility. standard level of evidence
the treatment Staniszews Berg Intervention: physical to support using
of balance ki,et al. Balance Scale Interventions therapy group commercially
deficits in (BBS) included were found to available VR
patients Dynamic balance balance-based have slightly gaming systems
receiving was evaluated with physical higher for the treatment of
inpatient the Functional Gait therapy using a enjoyment at balance deficits in
rehabilitation Assessment (FGA) Nintendo Wii, mid- patients with a
for traumatic Wii balance game as monitored intervention, primary
brain injury scores were by a physical while those diagnosis of TBI
recorded from VRT therapist, and receiving the receiving inpatient
balance receipt of one- virtual rehabilitation.
board games that the on-one reality-based Additional
participant used and balance-based balance research of these
for which numeric physical intervention types of
scores were therapy were found to interventions for
available (Table-Tilt using standard have higher the treatment of
and Penguin Slide). physical enjoyment at balance deficits is
Scores therapy study warranted.
from games that modalities completion.
provided only a available for Both groups
level or per- use in the demonstrated
opponent result therapy improved
(Bowling and gym.During static and
Tennis) were not days 1 and 3 of dynamic
analysed. each week, balance over
participants the course of
performed the study,
8 minutes of with no
Table-Tilt and significant
7 minutes of differences
Tennis, while between
on days 2 and 4 groups.
they performed Correlational
8 minutes of analyses
Penguin Slide suggest a
and 7 minutes relationship
of Bowling. exists
between Wii
balance board
game scores
and BBS
scores for
measures
taken beyond
the
baseline
assessment
Feasibility of 2022 Primary measures Thirty-one No serious Virtual reality and
virtual reality Candy included recruitment individuals adverse treadmill training
and treality Taffertiler and enrollment with chronic events were are safe and
and treadmill et al. rates, retention, TBI with self- reported. All feasibile for
training in tolerance to reported and participants individuals with
traumatic intervention, objective completed all TBI. Participants
brain injury : completeness of balance deficits training show
a Randomized outcome measures, participated in sessions and improvements on
controlled and adverse events. a 4-week 12 assessments balance and
pilot trial Secondary measures session at all time mobility measures
included the intervention of points. following a 4-
Community Balance treadmill Recruitment, week intervention.
and Mobility Scale, training with enrollment, Future research is
10 Meter Walk Test, virtual reality, and retention needed to evaluate
6 Minute Walk Test, treadmill rates were the efficacy of this
and Timed Up and training alone, high. All intervention
Go. or standard of groups compared to other
care showed a modes of balance
overground trend toward and mobility
therapy. improvement training.
in all balance
and mobility
measures
following
treatment.
Benefits of Thornton,S 2005 The Activities- The AB The ABC greater enthusiasm
activity and Marshall et. specific Balance exercise group mean and knowledge
virtual reality al. Confidence Scale program scores for the was expressed by
based balance (ABC) combined AB group participants in the
exercise The Lower traditional increased VR group and their
programmes Extremity balance slightly each caregivers.
for adults Functional Scale training time Conclusions: Both
with (LEFS) (walking, from 74.6 to exercise
traumatic running) with 76.4 and programmes
brain injury: equipment like 78.2. Mean offered benefits in
Perceptions balls and group scores addition to
of participants stools. The VR for improved balance.
and their approach used VR also The VR
caregivers a modified increased participants had
IREX program, each time greater
requiring full- from 74.8 to improvements on
body 80.2 and quantitative
movements to 81.2. The measures and
interact with LEFS group provided more
virtual objects. mean scores comments
Virtual reality for the AB expressing
provides safe, group enjoyment and
graded improved improved
exercises with from 55.8 to confidence.
augmented 57.4 and 60. Applications in
feedback and For the VR terms of
can be tailored group, the community
to different group means reintegration and
complexity initially quality of life are
levels. It allows improved discussed
individuals to from 57.1
engage in to 59.2 and
interactive then
activities decreased
otherwise slightly at 3-
inaccessible month
due to physical follow-up to
or cognitive 58.8.
limitations. Although
Sessions lasted both exercise
50 minutes, groups
three times a improved on
 week for 6 both
weeks, at a measures, the
rehabilitation changes were
center. not
statistically
or clinically
significant.
Improving Saiwei 2011 The outcome After There were Neither traditional
Balance Skills Yang, PhD measures that were completing no significant treadmill nor VR
in Patients Wei-Hsung included for the their routine improvement treadmill training
Who Had Hwang, MS study were center of physical and s in COP- had any
Stroke Yi-Ching pressure (COP) occupational related effect on balance
Through Tsai, sway therapy measures skill during quiet
Virtual PhD(c) excursion, COP (including and stance, but VR
Reality maximum sway in ambulation symmetric treadmill training
Treadmill anterior-posterior with parallel index during improved
Training direction, COP bars, cycling, the quiet balance skill in the
maximum and hand stance, either medial-lateral
sway in medial- function in the VR direction better
lateral direction, training), all treadmill or than traditional
COP sway area, patients traditional training did. VR
bilateral limb- received treadmill treadmill training
loading symmetric additional training also improved
index, the sway treadmill group (P 9 balance skill
excursion values for training. The 0.05). during sit-to-stand
the paretic foot control group However, the transfers and the
(sway excursion/P), walked on a difference involvement of
paretic treadmill for 20 between paretic limb in
limb stance time minutes while groups after level walking more
(stance time/P), looking at a training in than the traditional
number of steps of botanical COP one did.
the paretic limb garden. The maximum
(number experimental sway in
of steps/P), and group used a medial-lateral
contact area of the treadmill with direction
paretic foot (contact interactive VR during the
A/P) during quiet scenes, quiet stance
stance, requiring was
sit-to-stand transfer, patients to step significant (P
and level walking. on a switch = 0.038).
with either Traditional
limb to make treadmill
the VR scene training
turn. The failed to
treadmill speed improve sit-
adjusted during to
each turn, and stand
patients made performance,
16 turns in each whereas VR
20-minute treadmill
session. Both training
groups trained improved
three times a symmetric
week for 3 index (P =
weeks, wearing 0.028) and
a suspension sway
harness for excursion (P
safety without = 0.046)
weight support. significantly
during sit-to-
stand
transfer.
The changes
of symmetric
index
between
groups were
 markedly
different (P =
0.045).
Finally, both
groups
improved
significantly
in stance
time/P, but
only VR
treadmill
training
increased
contact A/P
(P = 0.034)
after training
during level
walking. The
difference
between
groups during
level walking
was not
significant.

The Effect of Hsin- 2017 Berg Balance Scale Fifty patients Both groups VR balance
a Virtual Chieh Lee, (BBS), Functional with mild to exhibited training by using
Reality Game Chia- Reach Test, and moderate motor significant Kinect for Xbox
Intervention Lin Huang, Timed Up and Go deficits were improvement games plus the
on Balance Sui- Test (cognitive; recruited and over time in traditional method
for Patients Hua Ho et. TUG-cog) for randomly the BBS had positive
with Stroke: al balance evaluations; assigned to two (P = 0.000) effects on the
A Modified Barthel groups: VR and TUG-cog balance ability of
Randomized Index for activities plus standard test patients with
Controlled of daily living treatment group (P = 0.005). chronic stroke. The
Trial ability; Activities- and standard The VR VR group
specific Balance treatment (ST) group rated experienced higher
Confidence Scale group. In total, the pleasure than the
for balance 12 training experience as ST group during
confidence; and sessions (90 more the intervention.
Stroke Impact Scale minutes a pleasurable
for quality of life. session, twice a than the ST
The pleasure scale week) were group during
and adverse events conducted in the
were also recorded both groups, intervention
after each training and (P = 0.027).
session. performance However, no
was assessed at significant
three time difference
points (pretest, was observed
post-test, and in other
follow-up) by a outcome
blinded measures
assessor. within or
between the
groups. No
serious
adverse
events were
observed
during the
treatment in
either group.
Virtual Taesung In, 2016 Outcome measures The VRRT There were Applying VRRT
Reality Kyeongjin included Berg program, based statistically (even as a home
Reflection Lee , Balance Scale on Sutbeyaz et significant treatment) along
Therapy Changho (BBS), the al.'s method, improvement with a
Improves Song . Functional Reaching involved s in the conventional
Balance and Test (FRT), and the gradual task VRRT group rehabilitation
Gait in Timed Up and Go progression compared program for
Patients with (TUG) test (for over four with the patients with
Chronic dynamic balance weeks. In the control group chronic stroke
Stroke: ability), postural first week, for BBS, might be even
Randomized sway (for static participants FRT, TUG, more beneficial
Controlled balance ability), and observed the postural sway than conventional
Trials 10 meter walking movements of (mediolateral rehabilitation
velocity (10 mWV) their unaffected sway distance program alone in
for gait ability. lower limb, with eyes improving af
focusing on open and fected lower limb
ankle and hip eyes closed, function. Future
movements. In anteroposteri studies should
the second or and to investigate the
week, they tal sway effectiveness of
mimicked these distance with VRRT with
movements eyes open but optimal patient
with their not with eyes selection, and
affected limb. closed), and duration and
By the third 10 mWV intensity of
week, the (p<0.05). training.
program
combined
movements for
added
complexity,
requiring
participants to
mimic more
coordinated
motions. The
fourth week
introduced
tasks such as
pressing a
remote control
button with the
unaffected foot
and tapping the
floor rapidly,
while
continuing to
mimic
movements on
the monitor.
Each session
involved three
sets of 10
repetitions for
30 minutes,
five days a
week, over four
weeks. The
control group
followed the
same program
but only
observed their
unaffected limb
under a camera,
without seeing
the projected
 movements on
a monitor. All
participants
wore a
checklist to
ensure proper
completion of
tasks. The
exercise used a
23 cm × 30 cm
× 75 cm LCD
monitor for the
visual
feedback.
Effects of Vishal 2023 To assess mobility The VRT Between the Both vestibular
vestibular Sana, and balance, the protocol aimed VR and VRT rehabilitation
rehabilitation MSNMPTa Time Up and Go to improve groups, therapy and VR
therapy , Misbah test was used, the gaze stability, balance improved
versus Ghous, Dynamic Gait Index balance, and (P−.01) and dizziness, balance,
virtual reality MSNMPT was used to assess gait. Patients gait (P−.01) and gait in
on balance, et.al the gait, and the performed head were subacute stroke
dizziness, and Dizziness Handicap movements significantly patients.
gait in Inventory was used (side-to-side improved in However, VR was
patients with to determine the and up-and- the VR more effective in
subacute level of dizziness down) while group, while improving balance
stroke symptoms. focusing on a dizziness was and gait among
A randomized stationary significantly patients with
controlled target for 1 improved in subacute strokes.
trial minute, the VRT
progressing to group with P
more < .001. On
challenging within-group
tasks like comparison,
walking and both groups
standing from showed
sitting. Balance significant
exercises improvement
involved s in balance,
weight shifting gait, and
and head dizziness
rotations while with P
maintaining < .001.
stability. Gait
training
included
walking at
different
speeds, turning,
and walking
with head
movements,
advancing in
difficulty by
changing
surfaces and
eye conditions.
These exercises
were done for
30 minutes,
three times a
week for 8
weeks,
alongside
general
physical
 therapy.

The VR
treatment used
the Nintendo
Wii system,
with patients
standing on the
Wii Balance
Board and
interacting with
an avatar on the
LED screen.
The games, like
Table Tilt and
Ski Slalom,
were selected
based on the
patient's
condition and
adjusted in
complexity as
their abilities
improved. Each
session lasted
20 minutes,
with 5 minutes
for warm-up
and cool down,
and was
performed
three times a
week for 8
weeks under
supervision.

Effects of Jung-Ah 2022 The Wii Balance The study There were These results
Balance Kwon Board (WBB; involved 15 significant demonstrated that
Training Yoon- Nintendo, Kyoto, balance improvement Wii Fit balance
Using a Kyum Shin Japan) was utilized training s not only in training using
Virtual et.al to assess static sessions over 8 balance virtual reality
Reality standing weeks, confidence improved the
Program in balance.Body conducted and activities quality of life of
Hemiplegic composition using twice a week. of daily hemiplegic
Patients InBody (Biospace, The control living, but patients while
California, CA, group received also in body overcoming the
USA) was measured conventional composition, asymmetrical
to balance such as fat weight distribution
determine body training (30 proportion of the affected side
mass index (kg/m2 ) minutes per and via the self-
Berg balance scale , session), metabolic modulating
10 M walk test , including rate, in the biofeedback
Activity specific balance board intervention exercises
balance confidence, exercises, mat group
Fuctional activities, compared to
independence weight-shifting, the control
measure .The and walking group (p <
health-related exercises. The 0.05). In
quality of life was intervention particular,
assessed using group balance
EuroQoL 5 participated in confidence
Dimensions (EQ- Wii Fit training significantly
5D- (30 minutes per affected
5L) and EuroQoL session) using EuroQoL
Visual Analogue the Wii Visual
Scale (EQ-VAS). Balance Board, Analogue
with activities Scale
like jogging, according to
skiing, tilt-table stepwise
balancing, and multiple
heading regression
exercises, analyses in
designed to this study.
improve trunk
control,
postural
control,
dynamic
balance, weight
transfer, and
visual
perception.
Both groups
were assessed
on balance,
walking,
confidence,
body
composition,
and quality of
life.
 Pedro Scale Assessment of Included Studies
Title Authors Eligibili Rando Conceal Baseline Blindin Blindin Blindi >85% Intenti Betwe Point Total Score
ty m ed Compar g of g of ng of Meas- on-to- en- Meas (Excluding
Criteria Allocati Allocati ability Subject Therap Assess ures Treat Group ures Eligibility)
-on on s ists ors Obtai Comp &
-ned arison Varia
s bility
The Effect Min-Jae Yes Yes No Yes No No Yes Yes No Yes Yes 6/10
of Virtual Lee,
Reality Sun-Min
Balance Lee,
Training Hyun-
Program on Mo Koo
Balance
Ability and
Fall
Efficacy of
Stroke
Patients
Improving Saiwei Yes Yes Yes Yes No No Yes Yes Yes Yes Yes 8/10
Balance Yang,
Skills in Wei-
Patients Hsung
Who Had Hwang,
Stroke Yi-Ching
Through Tsai, Fu-
Virtual Kang
Reality Liu, Lin-
Treadmill Fen
Training Hsieh,
Jen-Suh
Chern
Virtual Taesung Yes Yes No Yes No No Yes Yes No Yes Yes 6/10
Reality In,
Reflection Kyeongji
Therapy n Lee,
Improves Changho
Balance and Song
Gait in
Patients
with
Chronic
Stroke:
Randomized
Controlled
Trials
Effects of Vishal Yes Yes Yes Yes No No Yes Yes Yes Yes Yes 8/10
Vestibular Sana,
Rehabilitati Misbah
on Therapy Ghous,
Versus Muham
Virtual mad
Reality on Kashif,
Balance, Abdulazi
Dizziness, z
and Gait in Albalwi,
Patients Rashida
with Muneer,
Subacute Mahnoor
Stroke: A Zia
Randomized
Controlled
Trial
Virtual C. Yes Yes No Yes No No Yes Yes No Yes Yes 6/10
Reality Tefertille
Game- r, M.
Based Thornton
Therapy for , S.
Treatment Dean, K.
of Postural Taylor,
and D. Marr,
Coordinatio H.
n Shikako-
Abnormaliti Thomas
es
Secondary
to TBI: A
Pilot Study
Virtual B. Yes Yes Yes Yes No No Yes Yes Yes Yes Yes 8/10
Reality for Zhang,
Limb Motor D. Li, Y.
Function, Liu, et al.
Balance,
Gait,
Cognition,
and Daily
Function of
Stroke
Patients: A
Systematic
Review and
Meta-
Analysis
A A. Yes Yes No Yes No No Yes Yes No Yes Yes 6/10
Comparison Esquenaz
of i, S. Lee,
Locomotor A.
Therapy Wikoff,
Intervention A.
s in People Packel,
With T.
Traumatic Toczylo
Brain Injury wski, J.
Feeley
Virtual L. M. Yes Yes Yes Yes No No Yes Yes Yes Yes Yes 8/10
Reality Mirelma
Therapy for n, J. L.
Improving Maidan,
Balance in H.
Older Shalev,
Adults With Y. Ben-
Stroke Haim, J.
Hausdorf
f, N.
Giladi
The Role of J. Yes Yes No Yes No No Yes Yes No Yes Yes 6/10
Virtual Cameira
Reality in o, S.
Motor Bermude
Learning z, P.
and Postural Verschur
Control e
Rehabilitati
on
Effects of I. J. de Yes Yes Yes Yes No No Yes Yes Yes Yes Yes 8/10
Virtual Rooij, I.
Reality G. van de
Training on Port, J.
Balance and G.
Gait Ability Meijer
in Patients
With
Stroke:
Systematic
Review and
Meta-
Analysis
Video Game S. S. Yes Yes No Yes No No Yes Yes No Yes Yes 6/10
Therapy for Straudi,
Balance C. P.
Rehabilitati Antonuc
on in ci, A. S.
Chronic Nardone,
Traumatic N. B.
Brain Gandolfi
Injury: A
Randomized
Controlled
Trial